Form 3604-1 (June 2013)FORM APPROVEDOMB NO. 1004-0001Expires August 31, 2016

Form 3604-1 (June 2013)FORM APPROVEDOMB NO. 1004-0001Expires August 31, 2016

U.S.DEPARTMENT
OFTHE INTERIOR / FREE USE APPLICATION AND PERMIT
MINERAL MATERIAL / BUREAU OF LAND MANAGEMENT
OFFICE: ______
APPLICATION / BLM CASE SERIAL NUMBER:
Name of applicant / Telephone / Email
Mailing Address / Street Address (if different from Mailing Address)
City / State / Zip code / City / State / Zip code
Kind of material / Quantity requested (cu.yds. or tons) / Requested permit term
Materials are to be used for:
Give legal land description for proposed source area: / Select one
Existing Mine Site
New Mine Site
Meridian / Township / Range / Section / Subdivision / Acres
I HEREBY AGREE TO COMPLY WITH the regulations at 43 CFR, Part3600 and the stipulations and special conditions as set forth below. I CERTIFY That the: (a) materials to be removed are to be used for the purpose noted above; (b) none of the materials removed are to be sold or bartered; (c) removal of materials can begin only upon receipt of an approved copy of this permit and must cease upon the expiration date; and, (d) the Bureau of Land Management (BLM) must be notified upon completion of removal.
I CERTIFY That I am a citizen of the United States, and of the age of majority in the State in which I reside, and that this entity is qualified to apply for a free use permit to extract and use mineral materials under 43 CFR 3604.12 asa (Select one)Federal, State, or territorial agency, unit, orsubdivision (including municipalities), or non-profit organization.
I FURTHER CERTIFY That the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.
______(Signature of Applicant) ______(Date)
Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United States any false, fictitious, or fraudulent statements or representations.
If you are a non-profit organization or quasi-governmental agency, attach organization charter and other proof of status.
NOTICES
The Privacy Act of 1974 and the regulations in 43 CFR 2.48(d) provide that you be furnished with the following information required by this application:
AUTHORITY: 30 U.S.C. 601; and 43 CFR Part 3600
PRINCIPAL PURPOSE: BLM uses the information to maintain an inventory of mineral information, to adjudicate your rights to mineral resources, and to identify the parties applying for and/or granted permits for disposing of mineral materials.
ROUTINE USES: BLM will disclose the information on this form pursuant to the regulations in 43 CFR 2.56.
EFFECT OF NOT PROVIDING THIS INFORMATION: If you do not furnish all the information required by this form, your application may be rejected.
The Paperwork Reduction Act of 1995 requires us to inform you that:
The BLM collects this information to evaluate the amount and condition of mineral materials on public lands and it will be used to maintain depletion records.
The BLM is collecting this information to process your application and effect a binding permit.
The BLM will use this information to identify and communicate with applicants.
Response to this request is required to obtain a benefit.
The BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored information collection unless it displays a currently valid OMB control number.
BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 45 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004-0001), Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, NW, Room2134LM, Washington, D.C. 20240.
PERMIT / Expiration Date / Permit (Case) Serial Number
Permittee Name:
Legal land description of authorized permit area
Meridian / Township / Range / Section / Subdivision / Acres
This permit is issued under the Act of July 31, 1947, as amended, and 43U.S.C. 2 and 1201. Free use permits are issued subject to the requirements of 43 CFR Part 3600.
This permit is hereby issued for the materials applied for but may be canceled if it appears that this permit was issued erroneously or the terms or conditions contained herein are not observed.
The permit is subject to the following standard stipulations:
Any use of the surface of the lands involved in this permit must not interfere with any mining claim subject to the provisions of Section 4 of the Act of July 23, 1955(30 U.S.C. 612);
The permittee must allow BLM access for inspections as required by 43 CFR 3601.51
The permittee must clean up all work areas and must remove or dispose of all refuse resulting from the permittee’s operations, and equipment, personal property, and improvements must be removed within ninety (90) days after the permit expiration date as required by 43 CFR 3601.52
An annual report indicating the amount (cubic yards or tons) of material removed must be filed with the BLM Field Office on the anniversary date of the permit, and within thirty (30) days after permit expiration.
The permit is also subject to the following special conditions :
SPECIAL CONDITIONS
Authorized term
______years ______months ______days / Authorized quantity, in-place
______cubic yards or ______tons
Check all that apply:
Permittee Mining and Reclamation plan is required per 43 CFR 3601.40-44
Permittee is responsible for reclamation of permit area
Financial Guarantee is required per 43 CFR 3602.14
Removal area is within Community Pit –Common Use Area - Serial No. ______
Permittee will perform reclamation in Community Pit – Common Use Area in lieu of reclamation fee
Permittee must follow/comply with BLM mining and reclamation plan
Permittee will pay a reclamation fee for Community Pit – Common Use Area as identified below:
Type of Material / Quantity
(cu. yds. or tons)
(select applicable in-place units) / Reclamation Fee
(select applicable in-place units) / TOTAL Reclamation Fee
($)
$ per cubic yard / $ per ton
BLM will check this box if there are additional stipulations attached to this permit.
THE UNITED STATES OF AMERICA
By ______(Signature) ______(Printed Name)
______(Title) ______(Date)
______(BLM office)